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  • 1
    Online Resource
    Online Resource
    Coagulation Profile Changes Due to Thromboprophylaxis and Platelets in Trauma Patients at High-Risk for Venous Thromboembolism
    SAGE Publications ; 2015
    In:  The American Surgeon Vol. 81, No. 7 ( 2015-07), p. 663-668
    Details
    In: The American Surgeon, SAGE Publications, Vol. 81, No. 7 ( 2015-07), p. 663-668
    Abstract: We hypothesize there are coagulation profile changes associated both with initiation of thromboporphylaxis (TPX) and with change in platelet levels in trauma patients at high-risk for venous thromboembolism (VTE). A total of 1203 trauma intensive care unit patients were screened with a VTE risk assessment profile. In all, 302 high-risk patients (risk assessment profile score ≥ 10) were consented for weekly thromboelastography. TPX was initiated between initial and follow-up thromboelastography. Seventy-four patients were analyzed. Upon admission, 87 per cent were hypercoagulable, and 81 per cent remained hypercoagulable by Day 7 ( P = 0.504). TPX was initiated 3.4 ± 1.4 days after admission; 68 per cent received unfractionated heparin and 32 per cent received low-molecular-weight heparin. The VTE rate was 18 per cent, length of stay 38 (25–37) days, and mortality of 17.6 per cent. In all, 76 per cent had a rapid clotting time at admission versus 39 per cent at Day 7 ( P 〈 0.001); correcting from 7.75 (6.45–8.90) minutes to 10.45 (7.90–15.25) minutes ( P 〈 0.001). At admission, 41 per cent had an elevated maximum clot formation (MCF) and 85 per cent had at Day 7 ( P 〈 0.001); increasing from 61(55–65) mm to 75(69–80) mm ( P 〈 0.001). Platelets positively correlated with MCF at admission (r = 0.308, R 2 = 0.095, P = 0.008) and at Day 7 (r = 0.516, R 2 = 0.266, P 〈 0.001). Change in platelet levels correlated with change in MCF (r = 0.332, R 2 = 0.110, P = 0.005). In conclusion, hypercoagulability persists despite the use of TPX. Although clotting time normalizes, MCF increases in correlation with platelet levels. As platelet function is a dominant contributor to sustained trauma-evoked hypercoagulability, antiplatelet therapy may be indicated in the management of severely injured trauma patients.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/000313481508100713
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2015
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  • 2
    Online Resource
    Online Resource
    Minimally Invasive Hepatopancreatobiliary Surgery at a Large Regional Health System: Assessing the Safety of Program Expansion
    SAGE Publications ; 2023
    In:  The American Surgeon™
    Details
    In: The American Surgeon™, SAGE Publications
    Abstract: Complex, minimally invasive hepatopancreatobiliary surgery (MIS HPB) is safe at high-volume centers, yet outcomes during early implementation are unknown. We describe our experience during period of rapid growth in an MIS HPB program at a large regional health system. Methods During an increase in MIS HPB (60% greater from preceding year), hospital records of patients who underwent HPB surgery between 1/1/2019 and 12/31/2020 were reviewed. Operative time, estimated blood loss (EBL), conversion rates, length of stay (LOS), and perioperative outcomes were assessed. Results 267 patients’ cases were reviewed. The population was 62 ± 13 years, 50% female, 90% white. MIS was more frequently performed for hepatic than pancreatic resections (59% vs 21%, P 〈 .001). Open cases were more frequently performed for invasive malignancy in both pancreatic (70% vs 40%, P 〈 .018) and hepatic (87% vs 70%, P = .046) resections. There was no difference in operative time between MIS and open surgery (293[218-355]min vs 296[199-399] min, P = .893). When compared to open, there was a shorter LOS (4[2-6]d vs 7[6-10] d, P 〈 .001) and lower readmission rate (21% vs 37%, P = .005) following MIS. Estimated blood loss was lower in MIS liver resections, particularly when performed for benign disease (200[63-500]mL vs 600[200-1200] mL, P = .041). Overall 30-day mortality was similar between MIS and open surgery (1.0% vs 1.8%, P = 1.000). Discussion During a surgical expansion phase within our regional health system, MIS HPB offered improved perioperative outcomes when compared to open surgery. These data support the safety of implementation even during intervals of rapid programmatic growth.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/00031348231192073
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2023
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  • 3
    Online Resource
    Online Resource
    Patients with Risk Factors for Complications Do Not Require Longer Antimicrobial Therapy for Complicated Intra-Abdominal Infection
    SAGE Publications ; 2016
    In:  The American Surgeon Vol. 82, No. 9 ( 2016-09), p. 860-866
    Details
    In: The American Surgeon, SAGE Publications, Vol. 82, No. 9 ( 2016-09), p. 860-866
    Abstract: A prospective, multicenter, randomized controlled trial found that four days of antibiotics for source-controlled complicated intra-abdominal infection resulted in similar outcomes when compared with a longer duration. We hypothesized that patients with specific risk factors for complications also had similar outcomes. Short-course patients with obesity, diabetes, or Acute Physiology and Chronic Health Evaluation II ≥15 from the STOP-IT trial were compared with longer duration patients. Outcomes included incidence of and days to infectious complications, mortality, and length of stay. Obese and diabetic patients had similar incidences of and days to surgical site infection, recurrent intra-abdominal infection, extra-abdominal infection, and Clostridium difficile infection. Short- and long-course patients had similar incidences of complications among patients with Acute Physiology and Chronic Health Evaluation II ≥15. However, there were fewer days to the diagnosis of surgical site infection (9.5 ± 3.4 vs 21.6 ± 6.2, P = 0.010) and extra-abdominal infection (12.4 ± 6.9 vs 21.8 ± 6.1, P = 0.029) in the short-course group. Mortality and length of stay was similar for all groups. A short course of antibiotics in complicated intraabdominal infection with source control seems to have similar outcomes to a longer course in patients with diabetes, obesity, or increased severity of illness.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/000313481608200951
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2016
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  • 4
    Online Resource
    Online Resource
    Early Craniectomy Improves Intracranial and Cerebral Perfusion Pressure after Severe Traumatic Brain Injury
    SAGE Publications ; 2018
    In:  The American Surgeon Vol. 84, No. 3 ( 2018-03), p. 443-450
    Details
    In: The American Surgeon, SAGE Publications, Vol. 84, No. 3 ( 2018-03), p. 443-450
    Abstract: After traumatic brain injury, decompressive craniectomy (DC) is a second-tier, late therapy for refractory intracranial hypertension. We hypothesize that early DC, based on CT evidence of intracranial hypertension, improves intracranial pressure (ICP) and cerebral perfusion pressure (CPP). From September 2008 to January 2015, 286 traumatic brain injury patients requiring invasive ICP monitoring at a single Level I trauma center were reviewed. DC and non-DC patients were propensity score matched 1:1, based on demographics, hemodynamics, injury severity score (ISS), Glasgow Coma Scale (GCS), transfusion requirements, and need for vasopressor therapy. Data are presented as M ± SD or median (IQR) and compared at P ≤ 0.05. The study population was 42 ± 17 years, 84 per cent male, ISS = 29 ± 11, GCS = 6 (5), length of stay (LOS) = 32(40) days, and 28 per cent mortality. There were 116/286 (41%) DC, of which 105/116 (91%) were performed at the time of ICP placement. For 50 DC propensity matched to 50 non-DC patients, the midline shift was 7(11) versus 0(5) mm ( P 〈 0.001), abnormal ICP (hours 〉 20 mm Hg) was 1(10) versus 8(16) ( P = 0.017), abnormal CPP (hours 〈 60 mm Hg) was 0(6) versus 4(9) ( P = 0.008), daily minimum CPP (mm Hg) was 67(13) versus 62(17) ( P = 0.010), and daily maximum ICP (mm Hg) was 18(9) versus 22(11) ( P 〈 0.001). However, LOS [33(37) versus 25(34) days], mortality (24 versus 30%), and Glasgow Outcome Score Extended [3.0(3.0) versus 3.0(4.0)] did not improve significantly. Early DC for CT evidence of intracranial hypertension decreased abnormal ICP and CPP time and improved ICP and CPP thresholds, but had no obvious effect on the outcome.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/000313481808400332
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2018
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  • 5
    Online Resource
    Online Resource
    Does Isolated Hemoperitoneum Cause Peritonitis? A Review of 400 Trauma Laparotomies
    SAGE Publications ; 2016
    In:  The American Surgeon Vol. 82, No. 2 ( 2016-02), p. 183-185
    Details
    In: The American Surgeon, SAGE Publications, Vol. 82, No. 2 ( 2016-02), p. 183-185
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/000313481608200226
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2016
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  • 6
    Online Resource
    Online Resource
    Assessing Field Triage Decisions and the International Classification Injury Severity Score (ICISS) at Predicting Outcomes of Trauma Patients
    SAGE Publications ; 2017
    In:  The American Surgeon Vol. 83, No. 6 ( 2017-06), p. 648-652
    Details
    In: The American Surgeon, SAGE Publications, Vol. 83, No. 6 ( 2017-06), p. 648-652
    Abstract: Florida considers the International Classification Injury Severity Score (ICISS) from hospital discharges within a geographic region in the apportionment of trauma centers (TCs). Patients with an ICISS 〈 0.85 are considered to require triage to a TC, yet many are triaged to an emergency department (ED). We assess outcomes of those with an ICISS 〈 0.85 by the actual triage decision of emergency medical services (EMS). From October 2011 to October 2013, 39,021 consecutive admissions with injury ICD-9 codes were analyzed. ICISS was calculated from the product of the survival risk ratios for a patient's three worst injuries. Outcomes were compared between patients with ICISS 〈 0.85 either triaged to the ED or its separate, neighboring, free-standing TC at a large urban hospital. A total of 32,191 (83%) patients were triaged to the ED by EMS and 6,827 (17%) were triaged to the TC. Of these, 2544 had an ICISS 〈 0.85, with 2145 (84%) being triaged to the TC and 399 (16%) to the ED. In these patients, those taken to the TC more often required admission, and those taken to the ED had better outcomes. When the confounders influencing triage to an ED or a TC are eliminated, those triaged by EMS to the ED rather than the TC had better overall outcomes. EMS providers better identified patients at risk for mortality than did the retrospective application of ICISS. ICISS 〈 0.85 does not identify the absolute need for TC as EMS providers were able to appropriately triage a large portion of this population to the ED.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/000313481708300632
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2017
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  • 7
    Online Resource
    Online Resource
    Does Vasopressin Exacerbate Cerebral Edema in Patients with Severe Traumatic Brain Injury?
    SAGE Publications ; 2018
    In:  The American Surgeon Vol. 84, No. 1 ( 2018-01), p. 43-50
    Details
    In: The American Surgeon, SAGE Publications, Vol. 84, No. 1 ( 2018-01), p. 43-50
    Abstract: Arginine vasopressin (AVP) is often used as an alternative pressor to catecholamines (CATs). However, unlike CATs, AVP is a powerful antidiuretic that could promote edema. We tested the hypothesis that AVP promoted cerebral edema and/or increased requirements for osmotherapy, relative to those who received CATs, for cerebral perfusion pressure (CPP) management after traumatic brain injury (TBI). This is a retrospective review of 286 consecutive TBI patients with intracranial pressure monitoring at a single institution from September 2008 to January 2015. Cerebral edema was quantitated using CT attenuation in prespecified areas of gray and white matter. Results: To maintain CPP 〉 60 mm Hg, 205 patients required no vasopressors, 41 received a single CAT, 12 received AVP, and 28 required both. Those who required no pressors were generally less injured; required less hyperosmolar therapy and less total fluid; and had lower plasma Na, lower intracranial pressure, less edema, and lower mortality (all P 〈 0.05). Edema; daily mean, minimum, and maximum Na levels; and mortality were similar with AVP versus CATs, but the daily requirement of mannitol and 3 per cent NaCl were reduced by 45 and 35 per cent (both P 〈 0.05). In patients with TBI who required CPP therapy, AVP reduced the requirements for hyperosmolar therapy and did not delay resolution or increase cerebral edema compared with CATs.
    Type of Medium: Online Resource
    ISSN: 0003-1348 , 1555-9823
    URL: Article
    DOI: 10.1177/000313481808400121
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2018
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